When a workplace injury happens, the immediate priority is caring for the injured employee. Once medical needs have been addressed, another critical responsibility begins — understanding why the incident happened, and what can be done to prevent it from happening again.
Often, employers stop their investigation after identifying the immediate cause. Outcomes include statements like “the employee wasn’t paying attention,” “they slipped,” or “they lifted incorrectly.” These conclusions may explain what happened, but they rarely explain why it happened. Effective investigations go deeper by identifying the underlying systematic conditions that allowed the injury to occur.
An effective injury investigation should be conducted as soon as possible after the incident while information is fresh. The investigation should include interviewing the injured employee and witnesses, documenting the facts, taking photos or videos of the scene, examining equipment or tools involved, as well as reviewing relevant policies, procedures, training records and maintenance records.
The purpose of a root-cause analysis is to not only identify the immediate cause, but also to determine the underlying organizational factors that contributed to the incident, so effective corrective actions can be implemented. Rather than assigning blame to an employee, a root-cause analysis focuses on improving system processes, and workplace conditions to reduce the likelihood of similar incidents in the future and it also demonstrates a commitment to employee safety.
Asking why something happened repeatedly encourages investigators to continue asking questions until they identify the underlying system issue that contributed to the event. For example, if an employee is injured after slipping on a wet floor, the initial answer may be that the floor was wet. However, continuing to ask why may reveal additional contributing factors: Why was the floor wet? Why was the condition not identified? Why was there no inspection process? Why were employees unsure how to report the hazard?
One effective way to organize a root-cause analysis is by examining three key concept areas: people, paper and place.
- People focuses on the individuals involved and the human factors that may have contributed to the incident, including training, supervision, communication, competency, workload, staffing, fatigue and accountability.
- Paper examines the systems and processes that guide the work, such as policies, procedures, inspections, job hazard analysis, inspections, maintenance records and documentation. This area helps determine whether expectations were clearly established and consistently communicated.
- Place evaluates the physical environment where the incident occurred, including equipment, tools, workspace conditions, housekeeping, maintenance and other environmental hazards that may have contributed.
By asking why multiple times, using the people, paper and place framework approach, organizations can move beyond simply identifying what happened and begin understanding why it happened. This allows leaders to develop corrective actions that address system weaknesses, reduce risk and create lasting safety improvements.
For those who would like to meet with a loss control consultant to discuss written procedures or training in incident investigations or root-cause analysis or any topic related to safety or risk management, contact Risk Management Services Loss Control staff at losscontrol@masc.sc.